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Parikh N, Woelber E, Bido J, Hobbs J, Perloff J, Krueger CA. Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program. J Arthroplasty 2024:S0883-5403(24)00434-0. [PMID: 38734329 DOI: 10.1016/j.arth.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS Data was obtained from the CMS QPP for total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS There were 4 TKA and 3 THA surgeons who were cost-efficiency outliers within our area. Outliers and nonoutlier surgeons had patients who had similar body mass index, American Society of Anesthesiologists Physical Status Score, and age-adjusted Charlson Comorbidity Index scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < .001; 0.94 versus 1.15, P < .001) and lower out-of-pocket costs ($86.10 versus $135.46, P < .001; $116.10 versus $177.40, P < .001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSIONS The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.
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Affiliation(s)
- Nihir Parikh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Erik Woelber
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Juneau Bone and Joint Center, Juneau, Alaska
| | | | - John Hobbs
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Perloff
- The Institute for Accountable Care, Washington, District of Columbia; The Institute for Healthcare Systems, Brandeis University, Waltham, Massachusetts
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Mastrokostas PG, Mastrokostas LE, Emara AK, Wellington IJ, Ginalis E, Houten JK, Khalsa AS, Saleh A, Razi AE, Ng MK. Modern Internet Search Analytics: Is There a Difference in What Patients are Searching Regarding the Operative and Nonoperative Management of Scoliosis? Global Spine J 2024:21925682241248110. [PMID: 38613478 DOI: 10.1177/21925682241248110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2024] Open
Abstract
STUDY DESIGN Observational Study. OBJECTIVES This study aimed to investigate the most searched types of questions and online resources implicated in the operative and nonoperative management of scoliosis. METHODS Six terms related to operative and nonoperative scoliosis treatment were searched on Google's People Also Ask section on October 12, 2023. The Rothwell classification was used to sort questions into fact, policy, or value categories, and associated websites were classified by type. Fischer's exact tests compared question type and websites encountered between operative and nonoperative questions. Statistical significance was set at the .05 level. RESULTS The most common questions concerning operative and nonoperative management were fact (53.4%) and value (35.5%) questions, respectively. The most common subcategory pertaining to operative and nonoperative questions were specific activities/restrictions (21.7%) and evaluation of treatment (33.3%), respectively. Questions on indications/management (13.2% vs 31.2%, P < .001) and evaluation of treatment (10.1% vs 33.3%, P < .001) were associated with nonoperative scoliosis management. Medical practice websites were the most common website to which questions concerning operative (31.9%) and nonoperative (51.4%) management were directed to. Operative questions were more likely to be directed to academic websites (21.7% vs 10.0%, P = .037) and less likely to be directed to medical practice websites (31.9% vs 51.4%, P = .007) than nonoperative questions. CONCLUSIONS During scoliosis consultations, spine surgeons should emphasize the postoperative recovery process and efficacy of conservative treatment modalities for the operative and nonoperative management of scoliosis, respectively. Future research should assess the impact of website encounters on patients' decision-making.
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Affiliation(s)
- Paul G Mastrokostas
- College of Medicine, State University of New York (SUNY) Downstate, Brooklyn, NY, USA
| | | | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Ian J Wellington
- Department of Orthopaedic Surgery, University of Connecticut, Hartford, CT, USA
| | | | - John K Houten
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA
| | - Amrit S Khalsa
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ahmed Saleh
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Afshin E Razi
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Mitchell K Ng
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
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Vazquez S, Dominguez JF, Wu E, Spirollari E, Soldozy S, Ivan ME, Merenzon M, Hanft SJ, Komotar RJ. High-Volume Centers Provide Superior Value of Care in the Surgical Treatment of Malignant Brain Tumor. World Neurosurg 2024; 183:e787-e795. [PMID: 38216033 DOI: 10.1016/j.wneu.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Improved outcomes in surgical patients have been associated with increasing volume of cases. This has led to the development of centers that facilitate care for a specific patient population. This study aimed to evaluate associations of outcomes with hospital characteristics in patients undergoing resection of malignant brain tumors. METHODS The 2016-2020 National Inpatient Sample was queried for patients undergoing resection of malignant brain tumors. Teaching hospitals with caseloads >2 standard deviations above the mean (140 cases) were categorized as high-volume centers (HVCs). Value of care was evaluated by adding one point for each of the following: short length of stay, low total charges, favorable discharge disposition, and lack of major comorbidity or complication. RESULTS In 3009 hospitals, 118,390 patients underwent resection of malignant brain tumors. HVC criteria were met by 91 (3%) hospitals. HVCs were more likely to treat patients of younger age or higher socioeconomic status (P < 0.01 for all). The Mid-Atlantic and South Atlantic regions had the highest percentage of cases and number of HVCs. Value of care was higher at HVCs (P < 0.01). Care at HVCs was associated with decreased complications (P < 0.01 for all) and improved patient outcomes (P < 0.01 for all). CONCLUSIONS Patients undergoing craniotomy for malignant brain neoplasms have superior outcomes in HVCs. Trends of centralization may reflect the benefits of multidisciplinary treatment, geographic preferences, publicity, and cultural impact. Improvement of access to care is an important consideration as this trend continues.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, New York, USA.
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Eva Wu
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Martin Merenzon
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Van Halm-Lutterodt NI, Pan A, Al-Saidi NN, Ye Z, Zhang Y, Zhou L, Yang J, Liu T, Liu Y, Kim SS, Lonner B, Hai Y. Postoperative complications following Schwab-grade-I versus Schwab-grade-II PCO in treating severe rigid kyphoscoliosis patients: comparative matched-group outcomes with minimum 2-year follow-up. Spine J 2023; 23:1908-1919. [PMID: 37619870 DOI: 10.1016/j.spinee.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND CONTEXT Standard partial facetectomies, (Smith-Petersen Osteotomy, (SPO), (Schwab-grade-I) and complete facet resection also known as Ponte osteotomy, (PO), (Schwab-grade-II) are narrowly akin and collectively appreciated as posterior column shortening osteotomies (PCOs). The former is considered a gentler osteotomy grade than the latter. The spine literature provides very little information on their comparison regarding perioperative complications and major curve correction rate outcomes. PURPOSE To determine whether Schwab-grade-I PCO (SPO) and Schwab-grade-II PCO (PO) are comparably safe in the surgical management of severe rigid scoliosis or kyphoscoliosis patients. STUDY DESIGN/SETTING Retrospective single-center comparative clinical study. PATIENT SAMPLE A total of 38 patients with severe rigid scoliosis or kyphoscoliosis were propensity score matched in this study, (SPO-treated); n=21 (55.30%) and (PO-treated); n=17 (44.70%), who underwent primary spinal deformity corrective surgery, respectively. OUTCOME MEASURES Outcomes included demographics, baseline pulmonary functional outcomes, perioperative complications incidence, hospital costs, Oswestry disability index (ODI), and the Scoliosis Research Society-22 (SRS-22) questionnaire scores. METHODS Following approval by the Institutional Review Board (IRB) of Beijing Chaoyang Hospital-Affiliated Capital Medical University in Beijing, out of a total of 82 consecutive surgical patients with complete data demonstrating severe and/or rigid spinal deformity, a pool of 38 of the 82 (46.3%) propensity-matched adult (≥18 years) patients with severe rigid scoliosis or kyphoscoliosis defined with a preoperative major curve magnitude of ≥80° on anteroposterior plain radiographs, and flexibility of <25% on bending plain radiographs who underwent primary spinal deformity corrective surgery were retrospectively evaluated. The patients were dichotomized into two osteotomy groups: standard (partial) facetectomy (SPO-treated), n=21 with an average age of 24.67 years, (Schwab-grade-I PCO) and complete facet excision, (PO-treated), (ie, Schwab-grade-II PCO), n=17 with an average age of 23.12 years. The minimum follow-up period was 2 years. Primary outcomes included baseline demographics and clinical features. Secondary outcomes included perioperative [intraoperative, immediate, and 2-year postoperative] complication rates. Tertiary outcomes included perioperative ODI and SRS-22 scores. Statistical analyses were carried out by Student t-test and Pearson's Chi-square test (Fisher's Exact Test), through Python statistical software package. Statistical significance was set at (p<.05). RESULTS Of the 38 matched severe rigid scoliosis or kyphoscoliosis patients, 55.30% (n=21) were SPO-treated and 44.70% (n=17) were PO-treated patients, respectively. The overall average age of patients was 23.97 years, with a female incidence of 76.32%. Major curve correction rates were 49.19% and 57.40% in SPO-treated and PO-treated patients, respectively, (p>.05). Immediately following surgery, comparable overall complication rates of 28.57% (n=6/21) versus 29.41% (n=5/17) were observed in the SPO-treated and PO-treated patients, respectively, (p=.726). We observed incidences of 9.52%, (n=2/21) versus 5.88%, (n=1/17) for surgical intensive care unit (SICU) admission, and incidences of 4.76%, (n=1/21) versus 5.88%, (n=1/17) for cardiopulmonary events in SPO-treated versus PO-treated patients following corrective surgery, respectively, (p>.05). The incidences of neurological deficits in the SPO-treated and PO-treated patients were respectively, 14.29%, (n=3/21) versus 17.65%, (n=3/17) immediately following surgery, (p>.05), and 0.00%, (n=0/21) in SPO-treated versus 14.28%, (n=3/21) in PO-treated patients at ≥2 years postoperative, (p<.05). Among the three patients that reported neurological deficits in the PO-treated group at ≥2 years postoperative, two patients had pre-existing baseline neurological deficits. The ODI score in the PO-treated group was significantly inferior at a minimum 2-year follow-up, (p<.05). CONCLUSIONS In the current study, both SPO-treated and PO-treated patients demonstrated statistically comparable surgical complications immediately following corrective surgery. Severe rigid kyphoscoliosis patients with preexisting baseline neurological deficits were more inclined to sustain neurological morbidity following corrective surgery. PCO corrective techniques are warranted as safe options for treating patients with severe rigid spine deformity phenotypes.
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Affiliation(s)
- Nicholas Ishmael Van Halm-Lutterodt
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; Department of Orthopedics and Neurosurgery Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Orthopedics Surgery and Neurosurgery, Inspired Spine Health, Burnsville, MN, USA; Department of Healthcare Leadership Program, School of Professional Studies, Brown University, Providence, RI, USA; Department of Orthopedics Surgery, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Aixing Pan
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Neil Nazar Al-Saidi
- Department of Medicine, Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Ziyang Ye
- Department of Orthopedics Surgery and Neurosurgery, Inspired Spine Health, Burnsville, MN, USA; Department of Business Analytics, University of Chicago, Chicago, IL, USA
| | - Yangpu Zhang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lijin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jincai Yang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tie Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuzeng Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Sunny Sik Kim
- Department of Orthopedics Surgery and Neurosurgery, Inspired Spine Health, Burnsville, MN, USA
| | - Baron Lonner
- Department of Orthopedics Surgery, The Mount Sinai Hospital, New York City, NY, USA
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Pardessus P, Loiselle M, Silins V, Horlin AL, Brouns K, Marsac L, Fait C, Ilharreborde B, Julien-Marsollier F, Dahmani S. The association between intraoperative fluid management and perioperative allogenic blood transfusion during adolescent idiopathic scoliosis surgery. Paediatr Anaesth 2023; 33:829-836. [PMID: 37386846 DOI: 10.1111/pan.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Bleeding and transfusion remain important concerns during surgical correction of scoliosis even when multiple conservative strategies, such as preoperative recombinant erythropoietin and/or antifibrinolytic agents, are used. The current work aimed to determine the impact of other potential risk factors, especially the volume of intraoperative fluid intake, on the perioperative risk of allogenic transfusion during surgical correction of adolescent idiopathic scoliosis. METHODS This prospective study included all cases of adolescent idiopathic scoliosis operated in a single center during 2 years (2018-2020). Predictors analyzed were as follows: body mass index, preoperative hemoglobin concentration, thoracoplasty, preoperative halo-gravity, volume of intraoperative crystalloid administration, use of esophageal Doppler (for goal-directed fluid therapy), and duration of surgery. Statistical analyses were performed using a multivariable logistic regression model. RESULTS Two hundred patients were included in the analysis. Multivariable analysis found: an increased volume of intraoperative crystalloid administration as a significant predictor of allogenic blood transfusion. Receiving operator characteristics analysis found the model exhibiting an area under the curve of 0.85 (95% confidence interval: 0.75-0.95). Optimizing stroke volume using esophageal Doppler was associated with a decrease in intraoperative crystalloid intake. CONCLUSION These results indicate a statistical association between the increase in crystalloid intake and the risk of allogenic blood transfusion during surgical correction of adolescent idiopathic scoliosis. Controlled studies are needed to address the causative relation between intraoperative fluid intake and the risk of allogenic transfusion.
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Affiliation(s)
- Pierre Pardessus
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Maud Loiselle
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Vilnis Silins
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Anne-Laure Horlin
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Kelly Brouns
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Lucile Marsac
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Charlotte Fait
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
| | - Brice Ilharreborde
- Université de Paris-Cité, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
- Department of orthopedic surgery, Robert Debré Hospital, Paris, France
| | - Florence Julien-Marsollier
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
| | - Souhayl Dahmani
- Université de Paris-Cité, Paris, France
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France
- FHU I2D2. Robert Debré Hospital, Paris, France
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